Basic Information
Provider Information | |||||||||
NPI: | 1033223706 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BLUEBONNET FAMILY CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 223 S ABE ST | ||||||||
Address2: |   | ||||||||
City: | SAN ANGELO | ||||||||
State: | TX | ||||||||
PostalCode: | 769036305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3256557969 | ||||||||
FaxNumber: | 3256557976 | ||||||||
Practice Location | |||||||||
Address1: | 2030 PULLIAM ST | ||||||||
Address2: |   | ||||||||
City: | SAN ANGELO | ||||||||
State: | TX | ||||||||
PostalCode: | 769055175 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3256530800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2006 | ||||||||
LastUpdateDate: | 10/23/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PEREZ | ||||||||
AuthorizedOfficialFirstName: | LILLIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3256557969 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | F9940 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0045MA | 01 | TX | BCBS OF TX | OTHER |